Endometrial destruction techniques for heavy menstrual bleeding.

BACKGROUND: Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women that can reduce quality of life and cause anaemia. First line therapy has traditionally been medical therapy but this is not always completely effective. Hysterectomy, often used after the failure of medical therapy, is 100% effective but is risky, costly and can cause complications. Endometrial ablation is less invasive, less costly and preserves the uterus. A large number of techniques have been developed to "ablate" (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which can be performed blind and are less time consuming. Many of these techniques are still under development, refinement and investigation.

OBJECTIVES: To compare the efficacy, safety and acceptability of methods used to destroy the endometrium to reduce HMB in premenopausal women.

SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (issue 4, 2001), Medline (1966 to September 2001), EmBase (1980 to August 2001), Current Contents (1993 to week 38, 2001), Biological Abstracts (1980 to June 2001), Psyclit (1967 to August 2001) and Cinahl (1982 to July 2001). We also searched the specialised register of the Cochrane Menstrual Disorders and Subfertility Group (August 2001). We also searched reference lists of articles and contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA: Randomised controlled trials comparing endometrial ablation techniques in women with a complaint of heavy menstrual bleeding without uterine pathology. The outcomes included reduction of heavy menstrual bleeding, improvement in quality of life, operative outcomes, satisfaction with outcome, complications and need for further surgery.

DATA COLLECTION AND ANALYSIS: The two reviewers independently selected trials for inclusion, assessed trials for quality and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials.

MAIN RESULTS: In comparing hysteroscopic techniques, the vaporising electrode procedure was less difficult to perform (OR=0.25, 95%CI 0.1, 0.7) and had less fluid deficit (WMD=-258mls, 95% CI -342.1, -174.0) than TCRE. The odds of fluid overload and equipment failure were higher ((OR=5.2, 95% CI 1.5, 18.4) and (OR=6.0, 95% CI 1.7, 20.9) respectively) for those women having laser as compared to TCRE (transcervical resection of the endometriuim). In comparing traditional hysteroscopic endometrial ablation with the newer 2nd generation techniques overall, the newer techniques took less time to perform (WMD=-11mins, 95% CI -18.6, -2.6) and were more likely to be performed under local anaesthesia (OR=7.6, 95% CI 1.1, 52.7) but had a greater chance of equipment failure (OR=4.1, 95% CI 1.1, 15.0). The reduction in heavy bleeding did not differ significantly between any of the groups.

REVIEWER'S CONCLUSIONS: Endometrial ablation techniques continue to play an important role in the management of HMB. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between methods and with the "gold standard" of TCRE difficult. Most of the newer techniques are performed blind and are technically easier than hysteroscopy-based methods. Overall, the existing evidence suggests success rates and complication profile of newer techniques of ablation compares favourably with TCRE, although technical difficulties with new equipment need to be ironed out.